WESTERN HEALTH CARE CORPORATION - DOC by fjzhxb

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WESTERN REGIONAL INTEGRATED HEALTH AUTHORITY OBSTETRICAL AND GYNECOLOGICAL CONTROL Physician’s Name_____________________ Office Address_____________________________ Home Address_____________________Office Tel______________Home Tel.______________ Has been assigned to the following medical staff classifications: Honorary____ Consulting____ Active________ Associate________ Courtesy________ YES NO

MAJOR OBSTETRICS Antenatal 1. 2. 3. 4. Amniocentesis External Version Shirodkar Suture Consultations

____ ____ ____ ____

____ ____ ____ ____

LABOUR Caesarean Section Hysterotomy Destructive Operations Delivery – Vacuum Extraction* - Mid Forceps (including rotations) - Breech - Primigravida - Multigravida* - Breech Extraction - Version and Extraction - Face and Brow ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____

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YES Delivery - Multiple Pregnancy* - 1. Vertex - 2. Other - Manual Removal of Placenta* - Repair Third Degree Tear* - Duhrssen’s Incisions - VBAC* - Repair of Cervical Laceration* Associated Privileges Appendectomy Sigmoidoscopy Cystoscopy GYNECOLOGY Culdoscopy Amputation of Cervix Closure – Fistula Vesicovaginal Rectovaginal Hysterectomy - Abdominal - Vaginal Hysteropexy ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____

NO ____ ____ ____ ____ ____ ____ ____ ____

____ ____ ____

____ ____ ____ ____ ____ ____ ____ ____

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GYNECOLOGY Oophorectomy and Salpingectomy Vulvectomy Tubal Ligation Laparoscopy Colposcopy Cryocautery to Cervix Marshall Marchetti Aldridge Sling Vaginoplasty Tuboplasty Laser Perineorrhaphy Bartholin’s Cyst 1. Excision 2. Marsupialization

YES ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____

NO ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____

MINOR OBSTETRICS 1. Delivery – uncomplicated - Cephalic - Low Forceps 2. Repair of Episiotomy 3. Fetal Scalp Clip ____ ____ ____ ____ ____ ____ ____ ____ ____ ____

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Post-Partum Tubal Ligation Circumcision of Newborn Incision of Breast Abscesses Minor Gynecology D & C – Diagnostic - Following missed incomplete abortion Biopsy of Cervix Electrocautery to Cervix

YES ____ ____ ____

NO ____ ____ ____

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____ ____ ____ ____

Notwithstanding the above requests for procedural privileges, definite privileges should not interfere with emergency patient care.

DATE: _________________________SIGNED: ______________________________________

DATE: _________________________SIGNED: ______________________________________ DISCIPLINE OF OBSTETRICS DATE: _________________________SIGNED: ______________________________________ CHAIR REGIONAL MEDICAL ADVISORY DATE: _________________________SIGNED: ______________________________________
WRIHA

Discipline of Obstetrics-Gynaecology Approved By: RMAC February 1998


								
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